Advances in Medical Education and Practice
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Open Access Full Text Article
Test Anxiety and Associated Factors Among
First-Year Health Science Students of University of
Gondar, Northwest Ethiopia: A Cross-Sectional
Study
Sisay Hanfesa
Tsinat Tilahun
Nigussie Dessie
Shegaye Shumet
Endalamaw Salelew
Department of Psychiatry, College of
Medicine and Health Sciences, University
of Gondar, Gondar, Ethiopia
Correspondence: Endalamaw Salelew
Department of Psychiatry, College of
Medicine and Health Sciences,
University of Gondar, P.O. Box: 196,
Gondar, Ethiopia
Tel +251910004711
Email esalelew@gmail.com
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http://doi.org/10.2147/AMEP.S275490
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ORIGINAL RESEARCH
This article was published in the following Dove Press journal:
Advances in Medical Education and Practice
Background: The experience of extreme worry and self-doubt before taking a test can
drastically hinder an individual’s ability to perform well and may lead to miserable. Studies
about test anxiety and associated factors among first-year health science students in Ethiopia
are limited. Therefore, this study is meant to provide essential data for future interventions.
Objective: To assess test anxiety and associated factors among first-year regular under­
graduate health science students of the University of Gondar, northwest Ethiopia, 2019.
Methods: An institutional-based cross-sectional study with a stratified random sampling
technique. Test anxiety was assessed using the Test Anxiety Questionnaire. Data were
analyzed using Statistical Package for Social Science (SPSS) version 20. Bivariate and
multivariate logistic regression analysis was performed. A P-value of less than 0.05 was
considered statistically significant in the multivariate analysis, and the strength of association
was measured using adjusted odds ratio at a 95% confidence interval.
Results: In this study, the prevalence of test anxiety was 54.7% (95% CI=49.40–60.20). The
result revealed that fathers’ education of grade 9–12 (AOR=0.31, 95% CI=0.14–0.69),
mothers’ education of grade 9–12 (AOR=2.43, 95% CI=1.07–5.47), psychological distress
(AOR=8.37, 95% CI=4.29–16.39), the field of studies; midwifery (AOR=3.56, 95%
CI=1.07–11.76), and medicine (AOR=6.79, 95% CI=1.64–28.22) were significantly asso­
ciated with test anxiety at a P-value<0.05.
Conclusion: The study found that test anxiety is a major problem of first-year under­
graduate health science students. Mothers’ education of grades 9–12, psychological distress,
midwifery, and medical field of studies were risk factors of test anxiety, whereas fathers’
education of grade 9–12 was protective for test anxiety. This showed that an increment in the
education of father and mother has a controversial effect on test anxiety. It can be reduced by
providing suitable trainings for first-year health science students in dealing with factors
causing test anxiety.
Keywords: test anxiety, undergraduate first-year, health science students, test anxiety
questionnaire, Ethiopia
Introduction
Anxiety is considered when the worry is excessive or disproportionate to the
underlying threat, involves the expectation of future threat, and it is often consid­
ered as a disease when associated with personal distress, abnormal behavior,
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Hanfesa et al
impaired concentration, or avoidance.1 Test-anxiety is a
physiological condition in which people experience
extreme stress, anxiety, and discomfort during or before
taking a test.2 In a test-oriented community, students’ life­
styles are considerably affected by their test performance.
Possibly due to the pressure to perform well, among other
factors, students often experience heightened stress and
anxiety during tests; thus, test anxiety is one of the factors
which are responsible for students’ underachievement and
low performance.3 The major factors causing examination
anxiety were excessive course load, fear of failure during
exam, and studying all night before exams.4 Studies
revealed that undergraduate students reported significantly
higher levels of test anxiety compared to graduate
students.5 Test anxiety is increasing in college students at
a concerning rate, as their responsibilities to get anoptimal
result increase, with family and personal pressure pushing
them to the edge, and is a common problem among first
year University students.6
Approximately 25–40% of US students suffer from test
anxiety.7 Many college students experience academic-
related anxiety during their collegiate careers. Previous
research suggests 10–35% of college students experience
functionally impairing levels of test anxiety,8 which are
negatively associated with the academic performance.9,10
Test anxiety can drastically hinder an individual’s abil­
ity to perform well, and negatively affects their social,
emotional, and behavioral development and feelings
about themselves and school.2,3 In the higher level, test
anxiety results in lower test scores, and there is an
increased relation of test anxiety, and test performance,
although adverse exam stress can also result in metabolic
syndrome, hypertension, and infertility.9 Students suffer
from low self-esteem, constantly looking at the time
clock, pencil tapping, and giving worrying gestures.9,11
Previous works revealed that the prevalence of test anxiety
ranged from 13.3−71% among undergraduate students,12–
23
and factors associated with test anxiety were; sex,
excessive course load, low self-efficacy, negative family
environment, and over protection, lack of self-confidence,
no educated at home, maladaptive perfectionism, and lack
of time for preparation.5,–24–29
Despite the severity of the problems, studies on the
prevalence and determinants of test anxiety among first-
year undergraduate health science students in Ethiopia are
limited. For the academic staff, knowing about test anxiety
and associated factors will help them to intervene in the
future. Therefore, this study will provide the necessary
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information about test anxiety and associated factors
among the study participants.
Methods and Materials
Study Setting
An institutional-based cross-sectional study was carried
out on first-year regular undergraduate health science stu­
dents at the University of Gondar, College of Medicine
and Health Sciences from May and June 2019. It is one of
the oldest Universities in the country, established in 1954,
located in Gondar town northwest, Ethiopia. It has both
postgraduate and undergraduate fields of study. The health
science college currently offers about 12 undergraduate
and 44 postgraduate degree programs. It has a total of
5,994 undergraduate students, and 813 first-year regular
undergraduates, with 352 female and 461 male students.
Population
All first-year undergraduate health science students at the
University of Gondar College of Medicine and Health
Sciences were the source population. Those students included
in the sample during the study period and from whom infor­
mation was collected were the study participants after exclud­
ing those who were ill (unable to attend the class), or post-
basic first-year health science students at the movement.
Sample Size Determination and Technique
The sample size was determined using a single population
proportion formula by assuming the prevalence of test anxi­
ety was 71%, taken from a study conducted in Addis Ababa
University among Technology students,23 with 95% of con­
fidence level, and a 5% margin of error; by adding a 10%
non-response rate, a total sample of 349 was obtained. A
stratified random sampling technique was used to recruit
participants. First, proportional allocation of the study parti­
cipants based on the number of students in a class was done,
and the sampling interval was calculated by dividing the
number of students in a class with the proportionally allo­
cated number, which is equivalent with the total number of
first year students divided by the sample (813/349 ≈ 2). Then,
the first participant was selected by lottery method.
Therefore, at every two regular interval, participants were
invited to participate in the study.
Measurement
The questionnaire had six sections. The first section con­
sists of the sociodemographic characteristics of the study
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participants. The second, test anxiety, was measured using
the Test Anxiety Questionnaire (TAQ). The tool has 10-
items, and each item is scored 1–5 according to specific
criteria; “How often each statement describes them?”
which is rated as 1 “never”, 2 “rarely”, 3 “half-time”, 4
“often”, and 5 “always”. The sum up scores ranges from
10–50. A score of 10–19 indicates do not suffer from test
anxiety, 20–35 indicates a moderate level of test anxiety,
and over 35 indicates severe test anxiety.30 Third, social
support: The Oslo 3-items social support questionnaire
was used to assess social support. The scores range from
3–14, and scores of 3–8 show poor social support, 9–11
shows moderate social support, and 12–14 shows strong
social support.31 Fourth, self-esteem: was measured using
the 10-item scale of Rosenberg’s self-esteem. The scale
measures global self-worth by measuring both positive and
negative feelings about the self. The scale consists of four
points of Likert scale (“0” strongly disagree, “1” disagree,
“2” agree, and “3” strongly agree). The scores range from
0–30. Scores from 0–15 shows low self-esteem, 15–25
shows normal self-esteem, and 25–30 shows high self-
esteem. Items 2, 5, 6, 8, and 9 are reverse scored.32
Fifth, psychological distress: The Kessler Psychological
Distress Scale is a 10-item scale. The scores range from
10–50. Scores from 10–19 show wellness, 20–24 shows
mild disorder, 25−29 shows a moderate disorder, and
30–50 shows a severe disorder.33 Sixth, academic related:
variables were assessed with a semi-structured question­
naire developed by the investigators after reviewing dif­
ferent literature.
Data Collection and Analysis
Data were collected using a self-administered English
version of the questionnaire by trained psychiatric nurses.
The collected data were checked for completeness and
consistency, and pre-coded, entered into EPI info version
7.0, and exported to SPSS version 20 for further analysis.
In a binary logistic regression analysis; variables found to
have a P-value of less than 0.25 were candidates for
multivariable logistic regression analysis. Variables
P-value<0.05 was considered as statistically significant in
the multivariate logistic regression analysis. The strength
of association was explained with an Odds ratio at 95%
confidence interval. The final compiled results were pre­
sented in the form of text, tables, pie charts, and graphs.
The Test Anxiety Questionnaires’ reliability was checked
in this research with Cronbach’s alpha (α=0.874).
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Ethical Considerations
Ethical approval was obtained from the Institutional
Review Board (IRB) of College of Medicine and Health
Science (CMHS) of the University of Gondar (UoG) with
the approval number of UoG-CMHS-187/19 and adminis­
tered to the study subjects before the data collection. The
participants were informed that the participation was
voluntary and received informed written consent from
study participants. Confidentiality was maintained by
omitting personal identifiers. A letter of permission was
obtained from the College of medicine and Health
Sciences University of Gondar.
Results
Socio-Demographic Characteristics
A total of 349 participants were invited, and there was a
response rate of 92.3%. Few participants (27, 7.7%)
agreed to participate but failed to complete, so were not
included. Around three-fifths (190, 59.0%), of the partici­
pants were males. The majority of the participants (236,
73.3%) were below the age of 21, 301 (93.5%) were
single, and 236 (73.3%) were orthodox by religion, 217
(67.4%) of the participants resided in urban areas. Some of
the participants (136, 42.2%, and 99, 30.7%) had father’s
and mother’s education certificate and above (Table 1).
Magnitude of Self-Esteem and Social
Support
Of the participants, 86 (26.7%), 214 (66.5%), and 22 (6.8%)
had low level, normal level, and high levels of self-esteem,
respectively. More than half of the participants (174, 54.0%)
had poor social support, 137 (42.5%) had moderate social
support, and 11 (3.4%) had strong social support.
Psychological Distress
Regarding psychological distress, 163 (50.6%) participants
had normal, 59 (18.3%) participants had mild psychologi­
cal distress, 47 (14.6%) participants had moderate psycho­
logical distress, and 53 (16.5%) participants had severe
psychological distress.
Magnitude of Test Anxiety
The magnitude of test anxiety defined by TAQ with a total
cutoff point of 20 and above was 54.7% with a 95% CI of
49.40–60.20. In the other three categories, 146 (45.3%)
participants were found to not suffer from test anxiety, 155
(48.1%) participants had a moderate level of test anxiety,
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Table 1 Sociodemographic Profiles of the Study Participants

(n=322)
Variables Variable Frequency Percentage
Categories

Age <21 (18–20) 236 73.3

≥21 86 26.7

Sex Male 190 59.0

Female 132 41.0

Marital status Single 301 93.5

Married 18 5.6 Figure 1 The magnitude of test anxiety of among first-year undergraduate health
Separated 3 0.9 science students of the University of Gondar, 2019 (n=322).

Religion Orthodox 236 73.3

Protestant 45 14.0 with mother’s educational status of grade 9–12 were 2.43-
Muslim 36 11.2 times more likely to develop test anxiety as compared to
Catholic/ 5 1.5
mother’s educational status of certificate and above
Adventist
(AOR=2.43, 95% CI=1.07–5.47), those with psychologi­
Father’s education Non-educated 42 13.0 cal distress were 8.37-times more likely to develop test
status Grade 1–4 44 13.7
anxiety as compared to having no psychological distress
Grade 5–8 48 14.9
Grade 9–12 52 16.1
(AOR=8.37, 95% CI=4.29–16.39), those in the midwifery
Certificate and 136 42.2 field of study were 3.56-times more likely to develop test
above anxiety, and those in the medicine field of study were 6.79-
Mothers’ Non-educated 77 23.9
times more likely to develop test anxiety compared to
education status Grade 1–4 39 12.1 nursing department students (AOR=3.56, 95% CI=1.07–
Grade 5–8 46 14.3 11.76; and AOR=6.79, 95% CI=1.64–28.22, respectively)
Grade 9–12 61 18.9 (Table 2).
Certificate and 99 30.7
above

Family’s residency Urban 217 67.4

Rural 105
and 21 (6.5%) participants had severe test anxiety
(Figure 1).
Factors Associated with Test Anxiety
In a bivariate logistic regression analysis; sex, age, field of
study, father’s education, mother’s education, self-esteem,
marital status, family residency, psychological distress,
alcohol ever use, and Grade Point Average (GPA) were
candidates for multivariate logistic regression analysis at a
P-value<0.25. In the final model; father’s education,
mother’s education, psychological distress, midwifery,
and medicine department students were significantly asso­
ciated with test anxiety at a P-value<0.05. In multivariate
logistic regression analysis, those with fathers’ educational
status of grade 9–12 were 70% more likely to develop test
anxiety as compared to fathers’ educational status of cer­
tificate and above (AOR=0.31, 95% CI=0.14–0.69), those
Discussion
32.6 In this study, the prevalence of test anxiety and its possible
associated factors were assessed. The study revealed that
significant proportions of first-year undergraduate health
science students had test anxiety. The prevalence of test
anxiety among study participants was found to be 54.7%.
This result is consistent with the magnitude of test anxiety
reported in studies carried out in Ethiopia (52.3%),12 Iran
(52.25%),15 and Turkey (48%).13 However, this finding is
lower than those of studies carried out in India (83%),34 and
(62.7%),20 in two different settings, the United Arab
Emirates (89.4%),16 Malaysia (61.6%),21 and Saudi Arabia
(65.3%).22 The possible reasons for the discrepancies might
be variations in study populations. For instance, this study
was carried out on first-year health science students in 12
fields of study, while only medical students who had chances
of an excessive course load were sampled in India20 and the
United Arab Emirates.16 Furthermore, nursing students were
dealt with in Malaysia and Saudi Arabia. Besides, differences
in findings also relate to the tools used. For example, the Test
Anxiety Inventory scale was put to use in the United Arab

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Table 2 Bivariate and Multivariate Logistic Regression Analysis of the Associated Factors (n=322)
Variables Category Test Anxiety COR (95% CI) AOR (95% CI)

Yes (%) No (%)

Age ≤20 (18–20) 112 (47.5) 124 (52.5) 0.72 (0.44–1.19) 0.94 (0.49–1.78)
>20 34 (39.5) 52 (59.5) 1 1

Marital status Single 140 (46.5) 161 (53.5) 0.46 (0.17–1.22) 0.35 (0.11–1.06)
Married/separated 6 (28.6) 15 (71.4) 1 1

Fathers’ education status Non-educated 12 (28.6) 30 (71.4) 2.28 (1.08–484) 1.24 (0.51–3.02)
Grade 1–4 17 (38.6) 27 (61.4) 1.45 (0.73–2.91) 0.82 (0.36–1.88)
Grade 5–8 19 (39.6) 29 (60.4) 1.39 (0.72–2.73) 0.63 (0.27–1.46)
Grade 9–12 33 (63.5) 19 (36.5) 0.53 (0.27–1.07) 0.31 (0.14–0.69)**
Certificate and above 65 (47.8) 71 (52.2) 1 1

Mothers’ educational status Non-educated 27 (35.1) 50 (64.9) 2.22 (1.20–4.10) 1.08 (0.32–3.63)
Grade 1–4 14 (35.9) 25 (64.1) 2.14 (0.99–4.60) 1.76 (0.52–6.03)
Grade 5–8 21 (45.7) 25 (54.3) 1.43 (0.71–2.88) 2.13 (0.74–6.06)
Grade 9–12 30 (49.7) 31 (50.8) 1.24 (0.65–2.35) 2.43 (1.07–5.47*)
Certificate and above 54 (48.4) 45 (45.5) 1 1

Family residency Urban 105 (54.5) 112 (51.6) 1 1

Rural 41 (39.0) 64 (61.0) 0.68 (0.43–1.11) 0.93 (0.42–2.15)

Self-esteem Low 25 (29.1) 61 (70.9) 6.51 (2.28–8.55) 2.37 (0.70–8.03)

Normal 105 (49.1) 109 (50.9) 2.77 (1.04–7.35) 2.04 (0.69–6.02)
High 16 (72.7) 6 (27.3) 1 1

Psychological distress No 130 (58.6) 92 (41.4) 1 1

Yes 16 (16.0) 84 (84.0) 0.14 (0.07–0.25) 8.37 (4.29–16.39)***

Field of study Nurse 15 (31.9) 32 (68.1) 1 1

Midwifery 14 (53.8) 12 (46.2) 1.95 (0.70–5.44) 3.56 (1.07–11.76)*
Psychiatry 9 (47.4) 10 (52.6) 0.78 (0.26–2.42) 1.95 (0.51–7.42)
Physiotherapy 8 (44.4) 10 (55.6) 1.01 (0.30–3.44) 1.59 (0.37–6.83)
Public health 12 (50) 12 (50) 1.15 (0.33–3.95) 2.99 (0.67–13.43)
Laboratory 6 (24.0) 19 (76.0) 0.92 (0.29–2.88) 1.63 (0.42–6.32)
Medicine 44 (63.8) 25 (36.2) 2.90 (0.85–9.93) 6.79 (1.64, 8.22)**
Anesthesia 7 (38.9) 11 (61.1) 0.52 (0.20–1.35) 0.95 (0.29–3.04)
Health informatics 9 (47.4) 10 (52.6) 1.44 (0.41–5.04) 2.01 (0.47–8.51)
Optometry 6 (42.9) 8 (57.1) 1.02 (0.30–3.44) 1.29 (0.32–5.27)
Environmental 5 (25.0) 15 (75.0) 1.22 (0.32–4.66) 3.18 (0.67–15.11)
Pharmacy 11 (47.8) 12 (52.2) 2.75 (0.75–10.11) 3.49 (0.76–16.10)

Grade point average <3.00 31 (43.1) 41 (56.9) 1.54 (0.85–2.76) 0.99 (0.46–2.16)
3.00–3.50 50 (38.8) 79 (61.2) 1.83 (1.11–3.03) 1.56 (0.81–2.99)
>3.50 65 (53.7) 56 (46.3) 1
Notes: *P-value<0.05, **P-value<0.01, ***P-value<0.001.
Abbreviation: NB, significance.

Emirates and Saudi Arabia, whereas the Visual Analog Scale
was utilized in India. Moreover, research results might also
vary due to the sociocultural differences of participants.
On the other hand, the prevalence of test anxiety is
higher than that of a study conducted on medical students
in Uganda (13.3%),14 India (37%),18 Malaysia (18.2%),17
and another study carried out among pharmacy students in
Malaysia (32.5%).19 The possible reason for the difference
might be the tools used. In Uganda, for instance, the
Hamilton Anxiety Rating Scale was employed, while the
Westside Text Anxiety Scale (WTAS) was utilized in
Malaysia, and the Test Anxiety Questionnaire was used

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Hanfesa et al
in the current study. As a matter of fact, sociocultural
variations are also responsible for the differences in
study results.
In this study, the finding showed that having a father
educated from 9–12 grade is less likely to cause test
anxiety as compared to having a father educated to certi­
ficate and above. On the contrary, having a mother edu­
cated to grade 9–12 grade is more likely to cause test
anxiety on students than having a mother educated to
certificate and above. This is inconsistent with previous
studies conducted in King Saud university, which indi­
cated that having a non-educational family status is a
risk factor to develop test anxiety.11,15 This means that
fathers educational status certificate and above are risk
factors for test anxiety, whereas mothers educated certifi­
cate and above are protective for test anxiety. In the pre­
vious works, overprotection, family pressure, and negative
home environment are risk factors for test anxiety.6,28
On the contrary, this is inconsistent with a study con­
ducted in Iran, to determine level of test anxiety and con­
tributing factors among freshman students,15 and needs
further study. The other reason might be when the parents
educational status is certifiable and above, the pressure that
the students get from their fathers to work hard to be disliked,
and getting from their mothers to work hard to be like them.
In this study, psychological distress was significantly
associated with test anxiety. This is supported by previous
works carried out on test anxiety and psychological dis­
tress. Therefore, use of effective psychological interven­
tions for test anxiety, to reduce psychological distress, and
to enhance academic motivations are required.17,19,22
In the current study, a medical field of study was
significantly associated to develop more test anxiety than
a nursing field of study. This is in line with previous
studies which reported on test anxiety among medical
students.14,18,34 This might be due to the students’ percep­
tions about the department, the excessive course load, and
the difference in the evaluation system. This study also
indicates that the midwifery field of study had a higher risk
to develop test anxiety than a nursing field of study. The
reason may be due to the discomfort and frustration they
face in the clinical attachments, in field of studies, and
their big concern on their skill practices. This area needs
further study.
Limitations
That the study used a standard tool to assess test anxiety
and associated factors is, we feel, its strength. On the other
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hand, the study was conducted at a single institution, and a
cross–sectional study design could not show the cause–
effect relationships.
Conclusion
In this study, the prevalence of test anxiety among study
participants was high and needs to address the underlying
conditions that interfere with learning ability. The result
revealed that mothers’ education from grade 9–12, psy­
chological distress, midwifery and medicine field of study
were risk factors associated with test anxiety and fathers’
educational status of grade 9–12 was a protective factor.
This showed that an increment in the education of father
and mother has a controversial effect on test anxiety. It can
be reduced by providing suitable training for first-year
health science students in dealing with factors causing
test anxiety.
Consent to Publish
Not applicable.
Abbreviations
AOR, adjusted odd ratio; COR, crude odd ratio; SPSS,
Statistical Package for Social Science; TAI, Test Anxiety
Inventory; TAQ, Test Anxiety Questionnaire; WTAS,
Westside Test Anxiety Scale.
Data Sharing Statement
The data and materials used in this study are available
from the corresponding author.
Ethics Approval and Consent
Ethical approval was obtained from the Institutional
Review Board (IRB) of the University of Gondar. Letter
of permission was obtained from the College of medicine
and Health Sciences University of Gondar. Informed writ­
ten consent from study participants. Confidentiality was
maintained by omitting personal identifiers. This study
was conducted in accordance with the Declaration of
Helsinki.
Acknowledgment
The authors are indebted to the University of Gondar for
funding this research. Our appreciation goes to the super­
visor, data collectors, and study participants.
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Author Contributions
All the authors made substantial involvement in the con­
ception, design, acquisition of data, or analysis and inter­
pretation of data; took part in drafting the article or critical
review of the manuscript for important intellectual con­
tent; agreed on the journal to which the article submitted;
will give final approval of the version to be published; and
agree to be accountable for all aspects of the work.
Funding
This research was funded by the University of Gondar.
Disclosure
The authors declare that they have no competing interests.
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